Radar on Medicare Advantage

Some of the most vulnerable seniors served by Medicare Advantage — Medicare-Medicaid dual eligibles — may face significant barriers to accessing integrated care plans, according to a study published April 18 in JAMA Network Open. The research, led by teams from Brown University and the University of Pennsylvania, analyzed data from the Medicare Health Outcomes Survey (HOS) collected between 2017 and 2019 and identified about 148,000 full-benefit dual eligible beneficiaries. The study aimed to compare health and demographic characteristics of beneficiaries across four distinct MA plan types with varying levels of integration for duals.

Humana Inc. on April 30 reported first-quarter financial results that generally met its expectations and affirmed an adjusted earnings per share (EPS) forecast of “approximately $16.25” for the full year. For the quarter ending March 31, Humana beat Wall Street’s projections with an adjusted EPS of $11.58, and reported an insurance segment medical loss ratio (MLR) of 87.4%, which was close to its previously disclosed estimate of “approximately 87.5%.” For the full year, it continues to expect an insurance MLR in the range of 90.1% to 90.5% and an individual MA membership decline of about 550,000, partly due to previously announced service area exits and plan reductions. During an April 30 conference call to discuss quarterly earnings, President and CEO James Rechtin said the company will continue to monitor trends such as “changes in consumer behavior” due to the Inflation Reduction Act. He also said Humana performed well during the Open Enrollment Period that ran from January to March. The insurer did not provide new clarity regarding its ongoing lawsuit against CMS, which alleges that CMS lowered the 2025 Star Ratings for “at least a dozen of Humana’s largest plans on the basis of just three phone calls that were handled by CMS in a manner inconsistent with the agency’s own regulations.” CMS had until April 28 to modify its decision regarding the insurer’s request for a revision and took no action, meaning its appeal is officially denied.

Since the April 3 confirmation of Mehmet Oz, M.D., as CMS administrator, news from the agency has been emerging at a dizzying pace, including the releases of the final Medicare Advantage and Part D rule for plan year 2026, a host of other rules impacting Medicare providers, the separate MA final rate notice, and Oz’s “Vision for CMS.” But industry experts are looking just as closely as what’s left unsaid in these announcements to tell us about the direction of government-sponsored programs under President Donald Trump’s Make America Healthy Again agenda.  

“When we think about what was in and what was out [of the 2026 final rule], many professionals saw what was out and made a conclusion before they realized the speed and other mechanisms by which new rules are undoubtedly going to be made quickly in the next months,” points out Melissa Newton Smith, founder of Newton Smith Group.

The State Health Insurance Assistance Program (SHIP) was designed to offer free, unbiased information to Medicare beneficiaries about their coverage options, serving as a counter to agents and brokers who get paid to sell Medicare Advantage plans and other coverage. But a recent study published in JAMA Network Open revealed major gaps in the accuracy and completeness of information provided to seniors by SHIP, and the findings were particularly grim for Medicare-Medicaid dual eligibles. Those findings are especially timely as CMS Administrator Mehmet Oz, M.D., at his Senate confirmation hearing signaled an interest in reforming Medicare sales. Also, the Medicare Payment Advisory Commission recently discussed SHIP as a potential alternative to agents and brokers. 

The study employed mystery shoppers to evaluate the quality of counseling sessions across 131 SHIP sites in 16 states. Shoppers either visited SHIP sites in person or contacted them via phone or video calls. Of the 306 mystery shopping encounters, nearly 40% were not completed, largely due to a lack of return calls from SHIP counselors, which researchers said could indicate capacity constraints. All of the in-person shops, meanwhile, were completed.

On April 4, CMS released its highly anticipated rule finalizing Medicare Advantage and Part D program changes for 2026 that were introduced under former President Joe Biden. Nearly 300 pages shorter than the November version proposed by CMS, the final rule left out 12 sections altogether, including one seeking to expand coverage of anti-obesity medications and others that would have impacted MA plans' marketing practices and use of artificial intelligence, among other things. Industry experts say that doesn’t mean the agency won’t revisit those topics and put its own stamp on them under President Donald Trump.

“What was in [the final rule] was very little. Other than closing the chapter for now on GLP-1s and a few little relatively innocuous pieces around dual eligibles, most everything else was tabled,” remarks Melissa Newton Smith, founder of Newton Smith Group.